Provider Demographics
NPI:1346355930
Name:ELLIS, HOWLAND HIRAM
Entity type:Individual
Prefix:
First Name:HOWLAND
Middle Name:HIRAM
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5091 SAN MIGUEL ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-5630
Mailing Address - Country:US
Mailing Address - Phone:850-259-9501
Mailing Address - Fax:850-994-6958
Practice Address - Street 1:1015 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6738
Practice Address - Country:US
Practice Address - Phone:850-259-9501
Practice Address - Fax:850-994-6958
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW29131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical